- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,445.44 / $2,238.72
| Facility | | $758.58 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $147.91 / $245.47
| Professional | | $112.20 | $147.91 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,981.07 / $5,370.32
| Facility | | $3,311.31 | $3,981.07 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $151.36 / $177.83
| Professional | | $104.71 | $151.36 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $162.18 / $416.87
| Professional | | $120.23 | $162.18 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,951.21 / $4,265.80
| Facility | | $831.76 | $2,951.21 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $138.04 / $213.80
| Professional | | $100.00 | $138.04 | $213.80 |